Elbow Injuries

July/August 2013 issue of Radiologic Technology

Directed Readings
In the Classroom

Instructions:
This presentation provides a framework for
educators and students to use Directed Reading
content published in Radiologic Technology. This
information should be modified to:
1. Meet the educational level of the audience.
2. Highlight the points in an instructors discussion or
presentation.

The images are provided to enhance the learning

experience and should not be reproduced for
other purposes.

Introduction

The elbow is a complex joint that supports forearm

movement and consequently is at risk for various
injuries and disorders. Elbow disorders can range from
chronic to acute problems, many of which can be
debilitating.
This article explains the functional anatomy of the
elbow joint and discusses the most common elbow
disorders and injuries. It also presents the most
common diagnostic imaging choices, along with typical
acquisition methods.

Elbow

The functionality of the upper extremity relies on elbow

motion. If a persons elbow motion decreases by 50%,
upper extremity impairment increases by as much as
80%. The elbow controls pronation, supination, flexion,
and extension of the forearm.
Pronation positions the forearm with the palm facing
down and the arm extended. This position causes the
paths of the radius and ulna to cross at the midpoint of
the shafts. Supination of the forearm brings the palm of
the hand face up with the forearm extended. This
position brings the radius and ulna parallel with each
other.

Elbow

The elbow joints ability to flex and extend depends on the

articulation of the ulna and humerus. Pronation and
supination depend on the radial head and capitulum of the
humerus. A fully working elbow should allow the forearm
to extend 145from full extension to full flexion and permit
a 180rotation during pronation or supination.
Elbow pain can be caused by a number of issues with the
joint or surrounding anatomy. Pain at the elbow also can
result from problems not related to the elbow joint, such
as cervical radiculopathy or referred shoulder pain. Most
commonly, elbow pain is due to periarticular causes or
problems specific to the elbow joint. Polyarticular causes,
or problems affecting many joints, also play a role in
elbow disorders. Chronic elbow injuries can be attributed

Functional Anatomy

The humerus, radius, and ulna are the 3 bones that

make up the elbow. Each bone is designed to allow the
elbow to act as a hinge joint. The distal humerus
contains the trochlea, capitulum, coronoid fossa,
olecranon fossa, radial fossa, medial epicondyle, and
lateral epicondyle. The proximal radius includes the
radial head, radial neck, and radial tuberosity. The
proximal ulna comprises the olecranon process,
coronoid process, radial notch, and trochlear notch.
Within the elbow are the ulnohumeral, radiocapitellar,
and radioulnar joints, all of which lie within the same
joint capsule. The capsule has an internal synovial layer
and a superficial fibrous layer. Within these layers are 3
fat pads. The coronoid fossa and radial fossa both

Functional
Anatomy
The largest of the elbow joints is the ulnohumeral
articulation, which is a modified hinge joint. The trochlear
groove of the humerus holds the ulnohumeral articulation,
which allows for movement between the ulna and the
humerus.
The radiocapitellar joint is a ball and socket joint composed
of the radial head and humeral capitulum. This joint is lateral
to the ulnohumeral joint and allows for forearm supination
and pronation.
The radioulnar joint is a pivot type of synovial joint (a freely
movable joint that contains fibrocartilage and hyaline
cartilage layers and synovial fluid) divided into superior and
inferior sections. The superior section contains the
articulation between the radial head and the radial notch of
the ulna; the joint rotates within the annular ligament during

Functional Anatomy

The olecranon process is the bony prominence of the

ulna and also is where the triceps muscle attaches to
the elbow joint. The olecranon bursa is a fluid-filled sac
that provides a cushion between the bone and the slack
skin directly over the olecranon process. The
bicipitoradial bursa, or cubital bursa, lies between the
radial tuberosity and the biceps tendon. The
interosseous medial bursa lies medially between the
bicipitoradial bursa and the interosseous membrane of
the forearm.
Below the neck of the radius, the radial tuberosity lies
at the insertion point of the biceps tendon. The
brachialis muscle attaches at the coronoid process,
whereas the radial notch articulates with the radial

Elbow Ligaments

Ligaments provide stability for the elbow joint. The

medial and lateral collateral ligaments supply most of
the stabilization. The medial collateral ligament (MCL)
attaches the ulna to the medial epicondyle of the
humerus. The annular ligament loops around the radial
head. The lateral ligament attaches the lateral
epicondyle to the annular ligament.
The MCL also is called the ulnar collateral ligament
(UCL); it has 3 separate bundles and is essential to
stabilizing the ulnohumeral articulation of the elbow.
The ligament bundles are the anterior, transverse, and
posterior bundles. The most important of the elbow
stabilizing ligament bundles is the anterior bundle.

Elbow Ligaments

The lateral collateral ligament has 4 separate

structures: the annular ligament, the accessory lateral
collateral ligament, the lateral ulnar collateral ligament,
and the radial collateral ligament.
The annular ligament encompasses the radial head and
stabilizes the radial notch of the ulna by banding the
proximal radius to the proximal ulna. The accessory
lateral collateral ligament derives from the inferior
portion of the annular ligament and connects to the
supinator crest of the ulna. The lateral ulnar collateral
ligament begins at the lateral epicondyle and also
attaches to the ulnas supinator crest. The radial
collateral ligament begins at the lateral epicondyle and
inserts into the annular ligament.

Elbow Muscles

Four muscle groups, as well as the tendons, work

together to move the elbow joint. The muscle groups
are flexors, extensors, the extensor supinator group,
and the flexor pronator group. Three muscles within the
flexor group primarily act upon the elbow: the biceps
brachii, the brachioradialis, and the brachialis muscles.
The brachialis muscle and the biceps brachii are the
most powerful elbow flexor muscles.
The extensor group contains the triceps and anconeus
muscles. The triceps muscle and part of the anconeus
muscle control forearm extension. The extensor
supinator group contains the brachioradialis, supinator,
extensor digitorum, extensor carpi radialis longus and
brevis, extensor carpi ulnaris, and extensor digiti

Blood Supply and Elbow

Nerves
The blood supply through
the elbow is extensive, and

the major arteries involved with the elbow are the

brachial artery, radial artery, and ulnar artery. The
brachial artery is lateral to the median nerve and lies
within the cubital fossa of the elbow. Within the cubital
fossa, the brachial artery then bifurcates into the radial
and ulnar arteries.
Four nerves control elbow function and sensation. They
are the musculocutaneous nerve, median nerve, ulnar
nerve, and radial nerve. The brachial plexus of the
elbow is very complex, filled with a network of
peripheral nerves. The most accessible nerve is the
ulnar nerve. This nerve sits along the olecranon groove
and crosses the elbow through the cubital tunnel of the

Blood Supply and Elbow

Nerves
The radial nerve crosses
the elbow forward of the lateral
epicondyle. Radial nerve compression also is possible
because the nerve is susceptible to tightening of the
fibrous band that surrounds it.

The median nerve runs medially to the biceps tendon

and crosses the elbow from within the antecubital fossa.
At the elbow, the posterior interosseous nerve branches
off of the radial nerve. The musculocutaneous nerve
traverses the elbow through the lateral antecubital
fossa.

Bone Development

Bones develop in 3 distinct stages: during childhood,

adolescence, and young adulthood.
When viewing a radiograph of a pediatric patients
elbow, it is important to understand the ossification
centers or the order in which the elbow joint and bones
begin to develop. The order of bone growth is the same
for all pediatric patients, and the commonly accepted
mnemonic for this order is CRITOE (capitulum, radial
head, internal [medial] epicondyle, trochlea, olecranon
process, and external [lateral] epicondyle). Ossification
centers typically appear in girls 1 to 2 years before they
appear in boys.

Radiographic Anatomy

Radiographically, several important anatomical lines are

essential in assessing possible elbow damage in
patients. The radiocapitellar line should be centered
through the long axis of the radius and extend through
the radial neck to the center of the capitulum.
A lateral radiograph also should display the anterior
humeral line. This line should begin at the anterior
portion of the humerus and extend vertically through
the middle third of the capitulum. The coronoid line also
can be seen on the lateral image. This line should
proceed from the top of the coronoid process of the ulna
and proximally intersect the anterior portion of the
capitulum and trochlea.

Radiographic Anatomy

The lateral projection of the elbow also is essential in

evaluating the fat pads. The distal humerus contains 2
fat pads that make contact with the joint capsule on the
anterior and posterior portion of the joint.
Radiographically, this fat pad appears as a darker
density next to the bone with a grayer density of tissue
surrounding the edges. If the posterior fat pad is noted
by the radiologist, this is known as a positive fat pad
sign and indicates a probable fracture in approximately
90% of fracture cases.
Fat pads appear in the presence of a joint effusion when
the capsule that holds the fat pads distends. Correctly
positioning the patients elbow at 90is imperative
when imaging fat pads. A minor extension of the arm

Diagnostic Imaging
Modalities: Radiography

The most common findings are fractures, arthritis, loose

bodies, and destructive processes. Radiologic
technologists should obtain a minimum of 2 projections
with 90of differentiation because the elbow anatomy
appears normal in some projections even when the
patient has a disorder or injury in the area.
For the elbow, an anteroposterior (AP) projection and a
lateral projection should be taken. Other common elbow
projections include the medial and lateral oblique,
radiocapitellar, and the Jones method, also known as
the distal humerus acute flexion projection.

Radiography

In the AP projection, the patients elbow is extended

over the cassette. Supination of the hand prevents the
forearm bones from crossing. A slight lateral tilt of the
forearm can place the anatomy in the correct position.
The x-ray beam is perpendicular and centered to the
elbow joint.
When the patient cannot completely straighten the
elbow, 2 images replace the AP projection. Positioning
for both projections is similar to the AP projection, in
that the central ray is perpendicular to the joint.
However, the first projection places the posterior
surface of the humerus flat and parallel to the cassette.
For the second projection, the technologist places the
patients arm so that the posterior forearm is flat and

Radiography

Lateral images of the elbow require that the patient flex

the elbow 90. Both the forearm and the humerus
should be parallel to the surface of the cassette during
contact, and the radiologic technologist should rotate
the patients hand into a true lateral position. The
central ray should be directed perpendicular to the
elbow joint.
The medial oblique projection requires the patient to
extend the elbow over the cassette as in the AP
projection but with the arm and hand in a pronated
position. The internal oblique projection is positioned
similarly, but the arm should be rotated laterally until
the elbow is at a 45angle to the cassette.

Radiography

The radiocapitellar projection requires that the forearm

be imaged using a lateral projection but that the hand
and arm remain in a neutral rotation. The x-ray beam
points at a 45cephalic angle toward the shoulder,
centering on the elbow joint. The radiocapitellar
projection shows an oblique angle of the lateral elbow
separating the proximal radius and ulna.
The Jones method acquires images of the elbow in
complete flexion. The posterior aspect of the humerus
lies on the cassette with the forearm superimposed over
the top. The x-ray beam should be perpendicular to the
cassette and centered approximately 2 inches above
the olecranon process.

Magnetic Resonance
Magnetic resonanceImaging
(MR) imaging helps display the

joints muscle and tendon attachments. The ability to

evaluate much of the elbow anatomy would make MR
an optimal imaging choice except that positioning the
elbow is difficult using MR imaging.
For elbow MR, the patient can lie on his or her stomach
with the arm positioned above the head. Patients do not
tolerate this position well; therefore, the supine position
is used more frequently.
The classic MR acquisition for the elbow involves axial,
coronal, and sagittal images with T1- and T2-weighted
images.

Magnetic Resonance
MR images of the 3 Imaging
major nerves of the elbow generally
appear the same intensity as muscle on T1-weighted
imaging. The signal intensity is slightly higher with T2weighted images, but outlining and visualizing the
nerves depend somewhat on adjacent fat.

MR images of an injured ligament might show

thickening or thinning of the ligament, increased signal
intensity, hemorrhage, slackness, and other
abnormalities. Muscle injuries on MR scans show
morphological changes, atrophy, fatty changes, and
edema. Joint fluids increase with diseases that produce
synovial inflammatory changes. MR using gadolinium
contrast enhances the tissues signal intensity.

Computed Tomography

The rapid scanning and helical imaging of modern CT

scanners make accurate and prompt imaging of elbow
trauma possible. Planning for elbow surgery also
benefits from CTs ability to reformat images in any
plane required and to provide 3-D volume renderings.
CT displays fractures, loose bodies, osteochondral
lesions, and other bony abnormalities well. Aside from
fracture fragment evaluation, CT with IV contrast also is
beneficial for blood vessel evaluation following trauma.
Similar to conventional arthrography of the elbow, CT
arthrography can highlight the joint capsule and filling
defects from synovitis or loose bodies. CT arthrography
also is helpful in evaluating MCL tears.

Ultrasonography

Ultrasonography is not a typical choice for imaging the

elbow, but the modality offers a less expensive
alternative for evaluating tendons, ligaments, and
nerves.Ultrasonography is useful in diagnosing softtissue diseases of the elbow. It is also a good choice
when imaging infants and young patients to evaluate
unossified epiphyses that might not be noticeable on
radiographs.
Color-flow Doppler imaging can highlight soft-tissue
inflammation by showing increased blood flow to areas
of the elbow. Doppler imaging also can help distinguish
cystic from solid masses by displaying the vascular
components of the mass.

Elbow Disorders:
Olecranon
Bursitis
Inflammation of the olecranon bursa is called olecranon
bursitis. It is also referred to as students elbow because
the condition can be caused by leaning excessively on
the elbow. Chronic olecranon bursitis is seen in people
who throw repetitively, such as baseball pitchers; acute
cases usually occur after a direct fall onto a hard
surface.
Patients with bursitis are easily identified by the large
amount of swelling and masslike appearance of the
elbow. In nontraumatic situations, imaging may not be
required if the bursa fluid can be aspirated. In traumatic
situations, however, the bursa can become inflamed
because of an olecranon fracture. Fluid aspiration

Cubital Bursitis

Cubital bursitis also is known as bicipitoradial bursitis,

and symptoms include antecubital fossa swelling and
tenderness.
MR imaging of cubital bursitis shows high-signal fluid
that emerges between the radial tuberosity and biceps
tendon distally. The fluid normally appears on T2weighted images, which can lead to misdiagnosis of a
soft-tissue tumor. In questionable cases, IV contrast
assists in the diagnosis. If the fluid collection does not
enhance, bursitis is the likely diagnosis.
During sonography, elbow extension is routine.
Sonograms of cubital bursitis can show fluid or
hypoechoic tissue that causes active distention of the

Tendonitis and Tendon

Tendonitis of the elbow isTears
due to inflammation of the
tendons. Tendonitis of the biceps muscle can lead to rupture
on either end. This condition commonly occurs after lifting
heavy objects and results in tenderness near the biceps
rupture site. On average, tendonitis of the biceps occurs in
men aged 45 to 60 years.
When the distal end of the biceps muscle ruptures,
symptoms include proximal elbow pain and weakness,
especially during supination. When the rupture occurs, the
patient can experience a snapping sensation followed by the
appearance of a bulbous deformity, or Popeye sign, near
the distal bicep.
Radiographs may show an avulsion fracture of the radial
tuberosity in cases of complete tears, but enlargement or
abnormality of the radial tuberosity is the most common

Tendonitis and Tendon

Triceps tendonitis is common
with repetitive elbow use
Tears
in young athletes. The individual often experiences a
sensation on the medial border of the elbow that
patients describe as something snapping into place.
As with bicep tears, MR and ultrasonography images
can help physicians distinguish tears from other
pathology.

Lateral Epicondylitis

Lateral epicondylitis is the most common sports-related

injury of the elbow and a primary cause of elbow pain.
The mechanism of injury depends on repeated, forceful
contraction of the wrist extensor muscles; contraction
occurs with frequent forearm pronation and supination,
along with wrist extension. The abuse of the extensor
muscles causes inflammation at the lateral epicondyle.
Lateral epicondylitis is frequently referred to as tennis
elbow. Although the condition is associated with tennis,
many other repetitive motions can cause epicondylitis.
Estimates show that 90% of lateral epicondylitis
patients develop the disorder from activities other than
tennis.

Lateral Epicondylitis

The pain felt with lateral epicondylitis normally occurs

at the lateral epicondyle or slightly outside the elbow.
Gripping items may become difficult because of
weakness and increased pain within the forearm. This is
known as the coffee cup sign.
Radiographic evidence of lateral epicondylitis is rarely
found. In any case, radiographs differentiate lateral
epicondylitis from other disease processes of the elbow
such as arthritis or loose bodies.

Lateral Epicondylitis

Regardless of whether the tendonosis is located

medially or laterally, MR imaging demonstrates the
same epicondylitis features on either side.
Ultrasonography can find calcifications or hypoechoic
areas in the lateral epicondyle region and may be useful
in diagnosing tendonosis.
In cases of chronic lateral epicondylitis, the capsule
below the extensor carpi radial brevis (ECRB) tendon
should be examined for tears.
Currently, the best modality for diagnosing capsular
tears is arthroscopic techniques. Although MR falls short
of accurately imaging capsular tears of the ECRB
tendon, CT arthrography has shown excellent success at

Medial Epicondylitis

Known to patients as golfers elbow, medial

epicondylitis is common in individuals who overuse their
wrist flexors and forearm pronator but is seen far less
frequently than lateral epicondylitis.
Medial epicondylitis primarily affects the insertion point
of the flexor carpi radialis. The patient presents with
pain at the medial aspect of the elbow.
As with lateral epicondylitis, radiographic evidence of
medial epicondylitis can be difficult to find, but small
calcifications or spurs next to the medial epicondyle are
common. MR imaging most often is used for diagnosis.

Arthritis

Arthritis is a joint disorder that results in inflammation

of the joints within the body. There are varying kinds of
arthritis, each exhibiting different causes and
symptoms. Regardless of the type of elbow arthritis, the
initial stages of pain management include pain
medication and physical therapy. Occasionally,
corticosteroid injections are used for pain management,
but physicians must use caution to ensure that the
injections do not lead patients into a false sense of
treatment and overuse of the elbow joint, causing
further deterioration.

Rheumatoid Arthritis

Rheumatoid arthritis is a severe form of arthritis that

progressively affects the bodys joint tissues. Joint
erosion and destruction are common because of the
severity of rheumatoid arthritis.
Rheumatoid arthritis commonly begins in the
radiocapitellar joint. The radial head may move out of
its regular position and cause problems with other
elbow anatomy.
Radiographs can monitor structural changes caused by
rheumatoid arthritis, but radiography is not the
preferred method for early disease assessment. Bone
erosion from rheumatoid arthritis is better displayed on
CT images than on MR images or radiographs.

Osteoarthritis

Arthritic conditions of the elbow are not uncommon, but

osteoarthritis of the elbow is rare. Osteoarthritis is much
more prevalent in weight-bearing joints, such as knees
and hips, and in the interphalangeal joints of the hand.
Patients with osteoarthritis affecting the elbow
experience the most pain during terminal flexion and
extension of the joint.
Radiographic evidence of osteoarthritis includes
osteophyte formation. These osteophytes usually are
near the ulnohumeral joint and occasionally impinge on
the ulnar nerve. MR and CT images of the elbow help
show the joint surfaces and detect loose bodies or
spurs.

Gout

Elevated uric acid levels can result in monosodium

urate crystals to infiltrate the synovial fluid of joint
spaces and lead to gout. Gout usually is found in the
joint spaces of the toes but can appear at the elbow.
Evidence of gout is obvious in patients with advanced
disease but is not often apparent on images of early
cases. MR images are better for evaluating synovial
involvement, and CT is better for displaying
intraosseous lesions. Ultrasonography also can highlight
thickening of the synovial fluid, along with
inflammation.

Overuse Conditions in
Children
Children also can have
elbow injuries and conditions

related to overuse of the elbow joint. Examples of these

problems, sometimes referred to as Little League elbow,
include traction apophysitis of the medial epicondyle,
Panner disease, and osteochondritis dissecans.

Traction Apophysitis of the

Medial
Epicondyle
Traction apophysitis of the medial epicondyle is
inflammation of the medial epicondyle due to an
avulsion tear or trauma. Because of the timing of
ossification in children, traction apophysitis is the most
common elbow injury in young children.
Approximately 97% of elbow problems in baseball
pitchers are associated with symptoms of the medial
elbow. The main symptom of apophysitis of the medial
epicondyle is pain immediately after a repetitive motion
such as throwing.
Radiographs of the elbow might show slight widening of
the apophysis, but this can be missed easily if the
radiologist does not review comparison radiographs of

Panner Disease

Osteochondrosis affects the ossification centers of

children when the bone degenerates and then begins to
regenerate, producing excessive calcification in some
areas. Panner disease is a form of osteochondrosis that
affects the capitulum of the elbow.
Panner disease is most common in preadolescent boys
and children younger than 10. Panner disease is the
most common reason for lateral elbow pain in young
children and routinely affects the dominant arm.
Radiographs can display sclerosis and areas of
decreased density at the capitulum. An MR series with
T1-weighted images might show fragmentation with
decreased signal intensity at the capitulum surface.

Osteochondritis Dissecans

A more advanced form of osteochondrosis is

osteochondritis dissecans. These lesions result from
death of the articular cartilage or subchondral bone of
the capitulum due to a lack of blood supply.
Subchondral bone provides cartilage support at
articulation sites. If the subchondral bone or cartilage is
slightly fractured, it is known as osteochondritis
dissecans.
Patients with these osteochondritis dissecans lesions
often have plica, an inflamed lining of the
radiocapitellar joint. Because the pain is located on the
lateral side of the elbow, radiocapitellar plica commonly
is misdiagnosed as lateral epicondylitis.

Osteochondritis Dissecans

Osteochondritis dissecans typically affects adolescent

athletes aged 11 to 21 years.

Osteochondritis dissecans is characterized by a dull

ache with no centralized location. The pain may
disappear when the child is resting then reappear
during strenuous activities. If fragments are loose in the
area, the joint may routinely catch or cause a popping
sensation.

Osteochondritis Dissecans

Radiographs typically are not very sensitive for

identifying loose bodies, and less than 30% of positive
loose bodies are found using radiography.
CT of the elbow joint can help physicians locate and
count loose bodies found throughout the elbow
compartments before the patient undergoes
arthroscopic procedures to remove the fragments.

On MR images, osteochondral lesions can be confused

with normal osseous variants of the elbow.
Ultrasonographic imaging of osteochondritis dissecans
is rare. Arthroscopy is used most often because it
remains a safe and effective way to diagnose and
evaluate osteochondritis dissecans or lesions of the

Nerve Damage

The most common nerve condition in the elbow is ulnar

neuritis. This inflammation of the nerve can cause
radiating pain from the posterior medial elbow to the
hand and fingers. Compression of the elbow nerves is
attributed to a wide range of abnormalities.
An ulnar nerve injury typically is associated with
supracondylar fractures when the arm is in
hyperflexion, but most ulnar nerve injuries occur
because of direct blows to the nerve. Damage to the
ulnar nerve can lead to numbness and tingling of the
hand.
In severe cases of ulnar nerve injury, symptoms can last
for years after the trauma. This is commonly known as

Elbow Injuries: Ligament

or
Tendon
Injury
About 50% of the medial and lateral plane of the elbow
is stabilized by ligaments. If the anterior bundle of the
elbows MCL is injured, the elbow becomes extremely
unstable except when fully extended.
Radiography can assess ligament tears and joint
stability, particularly with valgus or varus stress applied
during a fluoroscopic examination.
Gadolinium contrast often is used during MR imaging to
help enhance MCL injuries. Although MR imaging is
highly sensitive for complete tears of the MCL, it is not
the method of choice for viewing partial tears. CT
arthrography has a higher rate of identifying partial
tears. In either modality, a sagittal projection is the best

Dislocations

The elbow is the joint that is dislocated most often

among pediatric patients. It is the second most
dislocated joint in adult patients, with 50% of cases
resulting from sports activities.
Elbow dislocations can occur as a result of many
situations but most often arise from a fall on an
outstretched hand. The most common dislocation
involves displacement of both the ulna and radius.
Elbow dislocations often present with other injuries. The
MCL is routinely compromised in elbow dislocation. With
MCL damage, the elbow joint might remain unstable
unless the ligament heals or is surgically repaired.
A patient with an elbow dislocation most often

Dislocations

An AP and lateral radiograph elbow series is sufficient to

diagnose an elbow dislocation.
An elbow reduction most often is completed by having
the patients upper arm held in place while applying a
steady pull on the forearm and hand. Once the
dislocation is reduced, the elbow should be tested for
mobility and examined with radiography to ensure
satisfactory reduction of the joint and exclude any
further bone injury.
A neurovascular examination should be performed and
results noted before and after reducing the elbow joint
dislocation. Following an elbow dislocation, extension
may become compromised and the elbow may be

Heterotopic Bone
Formation of boneFormation
or calcification that is not in the

normal bone growth area is called heterotopic bone

formation. Heterotopic bone growth at the elbow can be
associated with traumatic injury of the elbow, but
heterotopic bone formation of the elbow also can be
caused by central nervous system trauma or excessive
burns.
The formation of juxta-articular bone at the elbow joint
can cause problems because of decreased full range of
motion. Once elbow motion has been compromised by
heterotopic bone formation, the only treatment for
restoring motion is surgical resection of the bone.

Fractures

The proximity of nerves, arteries, tendons, muscle, and

bones in the elbow contributes to the elbow being
considered one of the most complex fracture sites. Clinical
examination begins by observing the patients arm. When
both arms hang normally at the patients sides, there
should be a 5 to 15separation of the forearms and hands
from the body. This arm-to-body separation is known as
the carrying angle. If the patients arms and hands are
not observed within the acceptable ranges, it could
indicate an elbow fracture. Any variation of the angle that
is more than 15is known as cubitus valgus. Angles less
than 5are called cubitus varus.
All fractures are serious and should be treated as such,
although open fractures are at higher risk for adverse

Distal Humerus Fractures

Distal humerus fractures represent only 2% of adult

fractures. These fractures can appear in both condyles
and often continue into the joint space.
Location determines the classification of distal humerus
fractures.
Patients with distal humerus fractures experience
extensive swelling, deformities, and pain. These
fractures also can produce bruising of the skin. Flexion
of the arm may produce crackling or popping sounds
from bone fragments.

Distal Humerus Fractures

A 2-projection radiographic examination usually is

sufficient to evaluate distal humerus fractures. A lateral
oblique projection is helpful for diagnosing lateral condyle
fractures or displacement. An oblique radiograph of the
elbow might help identify nondisplaced fractures of the
condyle in children.
Posterior displacement of the humerus, often seen in
fractures, affects the orientation of the anterior humeral
line seen on the lateral image. If the anterior humeral line
passes through the anterior portion of the capitulum or
does not meet the capitulum at all, a fracture is possible.
Displaced fractures are generally stabilized with surgery.
Splinting is sufficient in nondisplaced fractures. It is
important to retake radiographs of the elbow after several

Olecranon Process
The olecranon process
is at high risk for fracture
Fracture

because of its prominent position directly under the

surface of the skin. Olecranon process fractures
generally occur when an individual falls directly onto
the flexed elbow, resulting in a comminuted fracture.
Other fractures of the olecranon process include
avulsion, nondisplaced transverse and nondisplaced
oblique fractures, and fracture-dislocations. Swelling
and extensive bruising often are noted following an
olecranon process fracture.
AP and lateral radiographs can usually demontrate
olecranon process fractures, with a lateral projection
providing the best view of the fracture.

Olecranon Process
If an olecranon process
fracture is nondisplaced, a
Fracture

posterior splint to flex the elbow 90usually is the first

step in treatment. Follow-up for this treatment includes
radiography to ensure that the fracture remains
nondisplaced. Displaced fractures require internal
fixation with plates, screws, pins, or wires to align the
bone properly.
Even after healing, an olecranon process fracture can
produce loss of motion regardless of treatment. If
fixating hardware is used, the hardware can irritate the
tissues around the fracture site, causing more pain.

Coronoid Process Fracture

Fractures of the coronoid process typically occur in

conjunction with posterior elbow dislocations. An
avulsion fracture of the coronoid is possible if the
brachialis muscle is subjected to forceful contraction.
Antecubital fossa tenderness and swelling are common
symptoms of coronoid fracture.

The radial head or oblique projection of the elbow

highlights possible fractures of the coronoid. The lateral
projection best demonstrates coronoid fractures,
however, and also highlights avulsion fractures.

Radial Head Fracture

The radial head is believed to be the secondary

stabilizing source for the elbow during valgus stress. As
a result, radial head fractures tend to occur when
patients fall with a forearm turned inward and land on
an outstretched hand. These are the most common
elbow fracture among adults.
Patients who have radial head fractures experience pain
on the outer surface of the elbow and may not be able
to pronate or supinate the forearm. The elbow can show
signs of swelling, limiting the amount of flexion and
extension.
Standard 2-projection radiographs of the elbow are
routine for suspected radial head fractures because

Capitulum Fractures

Fractures of the capitulum are not very common, but when

they occur, they share a similar mechanism of fracture as
radial head fractures because of the axial alignment of the
capitulum. In fact, nearly 50% of capitulum fractures are
accompanied by a radial head fracture.
Results of routine radiography often are misleading in
cases of capitulum fracture. The AP projection can hide a
fracture fragment behind the humerus, and any rotation
or a slight oblique lateral positioning often obscures a
capitulum fracture. Radiographs of the elbow consistently
show a positive fat pad sign on the lateral projection, but
radiographers should acquire a radiocapitellar projection
to better demonstrate any fracture fragments.
Determining the degree of displacement in capitulum

Avulsion Fracture

Stress to the elbow joint can cause avulsion fractures.

Avulsion fractures often are found in adolescents aged 9
to 12 years, and they are the most common type of
elbow fracture in adolescent athletes who participate in
throwing as part of their sport.
Avulsion fractures most often are found before the
secondary ossification centers fuse. A common
symptom of avulsion fractures is an acute popping
sensation in the elbow followed by pain. The pain often
is felt immediately after making a hard pitch or throw.
Images obtained following the injury might show a
disconnection of the medial epicondyle apophysis or
subtle displaced fractures. Occasionally, a gravity stress

Combined Fractures and

Monteggia fracture-dislocations
involve a fracture of the
Dislocations
ulnar shaft and displacement of the radial head. If the
alignment of the radiocapitellar line does not point to
the capitulum on all radiographic projections, a
Monteggia fracture or lateral condyle fracture is likely.

Galeazzi fracture-dislocations combine a distal radial

head disruption with a distal radial fracture. EssexLopresti fracture-dislocation consists of a radial head
fracture that is comminuted and a distal subluxation or
dislocation of the radioulnar joint.
The terrible triad is a devastating elbow injury that
includes a radial head fracture, an MCL injury, and a
coronoid process fracture.

Arterial Injuries

Specific trauma, such as supracondylar fractures, carry

such a high risk for arterial injury thatarterial injury
should be suspected in most cases. Arterial injuries are
very serious and can lead to contracture or loss of the
affected limb.
If the brachial artery is damaged, the patient may have
a decreased pulse, radiating pain, decreased skin
temperature, and the skin of the affected arm may
appear pale. A pulse should be detectable distal to the
fracture. If the skin appears pale or the pulse is
noticeably low or absent, arterial injury is likely. A CT
examination with IV contrast can display any occlusions
or hematomas.

Fractures in Children

Fractures of the elbow are not uncommon in children,

given their typical behavior. Supracondylar fractures are
the most common elbow fracture in the pediatric
population, however, constituting up to 60% of cases.
After the reduction of a supracondylar fracture, a
radiographic image using the Jones method image can
confirm adequate reduction.
Roughly 35% of pediatric skeletal injuries involve a
growth plate. During the growth process, the long bones
of pediatric patients contain a physis or growth plate
that allows the bone to grow longitudinally. The bone in
the growth plate grows rapidly. This can benefit fracture
healing, but care must be taken when managing any
fracture that extends into the growth plate because the

Fractures in Children

If a posterior fat pad is seen on a lateral radiograph and

no other abnormality is seen, it is likely that the patient
has a nondisplaced intracapsular fracture. About 76% of
follow-up radiographs of pediatric patients show healing
fractures in the elbow area. These findings support the
decision to manage these situations as though a fracture
existed in the original radiograph. If a hairline or small
fracture is suspected after a negative radiographic
examination, pediatric patients can return sooner than
adult patients for repeat images because children have
faster callus formation.
Radiologic technologists and care providers should be
aware of specific elbow fractures that might indicate child
abuse. A transphyseal fracture of the humerus, common

Fractures in Children

The routine 3-projection radiograph of the elbow is not

always helpful to diagnose a transphyseal fracture
because of a lack of ossification in pediatric patients.
Comparison radiographs of the opposite elbow can
assist the radiologist in diagnosing transphyseal
fractures. If radiographs of the elbow are not definitive,
MR imaging, ultrasonography, or arthrography may be
required to confirm a diagnosis.
If a transphyseal fracture is found and child abuse is
suspected, the provider might want to order additional
radiographs. Child abuse victims often have fractures in
multiple areas of their bodies. The types of child abuse
fractures that might be seen in addition to the
transphyseal fracture are diaphyseal or long-bone shaft

Congenital Radial-Ulnar
Bones sometimesSynostosis
can fail to form as they should in

children. In congenital radial-ulnar synostosis, the

radius and ulna fail to grow apart at their proximal
locations. This condition can be bilateral or unilateral.
When the proximal radius and ulna are not freely
mobile, supination and pronation of the forearm is
limited.
Radiographs of the forearm confirm cross-synostosis of
the proximal radius and ulna. This appearance of the
bony union is easily seen by the increased bony
formation.

Radial Head Subluxation

Children who have loose ligaments are at risk for

subluxation of the radial head. Radial head subluxation
sometimes is called nursemaids elbow and is the most
common elbow injury in younger children. Most often,
radial head subluxation affects the left arm of children
who are between the ages of 2 and 3 years.

Problems with the radial head develop when a young

childs arm is pulled with forearm extension and pronation.
This injury often occurs when a child is pulled up by the
arm or suddenly drops to the floor to tug away from being
held.
Diagnosis of radial head subluxation is complicated by
young childrens inability to describe their symptoms in
detail. Radiographs of the elbow do not always show a

Conclusion

Elbow disorders and injuries can be painful and

problematic for patients and complex for the medical
professionals providing imaging and care.
Understanding the anatomy of the elbow and medical
diagnostic imaging methods to best demonstrate elbow
injuries and disorders helps radiologic technologists
enhance the diagnostic process and directly benefits
patient care.

Discussion Questions
Explain the radiologic modality choices for
diagnosing elbow disorders and injuries.
Discuss the most common elbow disorders
and injuries.
Discuss some of the differences between
pediatric and adult elbow anatomy as well
as different elbow disorders and injuries
specific to children and adults.

Additional Resources
Visit www.asrt.org/students to find
information and resources that will be
valuable in your radiologic technology
education.